Translation and Cross-Cultural Adaptation into French of the Birth Satisfaction Scale – Revised (BSS-R)

Introduction

Childbirth is a life-changing experience that can be perceived as either a positive or negative event by the mother. For many years, the delivery process was deemed as satisfying as long as the safety and physical health of the mother were not compromised. It is only recently that the mother’s perception and emotions have also been a consideration.^1,2 Those dimensions are of great importance since a dissatisfying experience can lead to severe impacts such as post-natal depression,³ post-traumatic stress disorder,⁴ future fear of giving birth⁵ or reluctance towards future childbirth⁶ resulting in impaired quality of life.⁷ On the other hand, a positive experience can be empowering and increase breastfeeding self-efficacy,⁸ improve the quality of the bond with the child,⁹ and promote personal growth and self-respect.¹⁰

Capturing the mothers’ perception of their delivery is essential to identify those at risk of post-partum complications and continuously improve quality of care through obtained feedback. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are useful tools increasingly used in routine care to achieve this, as they provide a standardized, unbiased assessment of the mother’s health state. Therefore, many have been developed such as the Women’s Views of Birth Labor Satisfaction Questionnaire,¹¹ the Childbirth Experience Questionnaire (CEQ),¹² the Mackey Childbirth Satisfaction Rating Scale¹³ or the Birth Satisfaction Scale-Revised (BSS-R).¹⁴

The BSS-R represents to date one of the most used questionnaires to assess birth satisfaction.¹⁵ It has been adapted from the original Birth Satisfaction Scale (BSS)¹⁶ and assesses factors influencing women’s birth experience. Furthermore, this instrument has shown robust psychometric properties, including high internal consistency and construct and divergent validity, while remaining brief with only 10 items.¹⁴ Therefore, the BSS-R was recently proposed by the International Consortium for Health Outcomes Measurement (ICHOM) as the measure of choice for measuring birth satisfaction in their standardized set of outcomes for pregnancy and childbirth.¹⁷ Since, this instrument has been widely adapted and tested in other languages, including Australian,¹⁸ Turquish,¹⁹ Hebrew,²⁰ Slovakian,²¹ Spanish,²² Persian,²³ Brazilian,²⁴ Italian,²⁵ Urdu,²⁶ Hindi-Indian,²⁷ Swedish,²⁸ Arabic,²⁹ Czech,³⁰ Dutch,³¹ Hungarian³² and Vietnamese.³³ Cultural adaptations have to be thoroughly conducted to ensure validity across different populations, as perceptions of childbirth can vary according to cultural norms. The aim of this study was to continue the internationalization of this questionnaire by developing a French-language version (Fr-BSS-R).

Materials and Methods

BSS-R Score

The BSS-R is composed of 10 items and is a reduction of the original BSS containing 30 items. Its psychometric properties have been validated in the original English version (UK-BSS-R) and in the various existing translations.¹⁴ This self-reported questionnaire is both valid and reliable for assessing postnatal women’s birth satisfaction.¹⁴ The BSS-R is constructed with three distinct domains including quality of care provision (4 items), women’s personal attributes (2 items) and stress experience during labour (4 items). Each item can be answered through a 5-point Likert scale, with total score ranging from 0 (least satisfaction) to 40 (most satisfaction).^14,16 Permission to adapt the BSS-R was obtained from the instrument’s developers.

Cultural Adaptation and Translation Process

The cross-cultural translation and adaptation were performed in line with the guidelines of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).³⁴ The procedure followed the standard 10-step approach, as previously described:^35–37 (i) preparation, (ii) forward translation, (iii) reconciliation, (iv) back translation, (v) back translation review, (vi) harmonization, (vii) cognitive debriefing, (viii) review of cognitive debriefing results, (ix) proofreading, and (x) final report (Figure 1). The study complied with ethical standards of the Declaration of Helsinki. Written informed consent was obtained from all participants, and given the qualitative and non-clinical nature of the study, prior approval from the local ethics committee (Geneva Ethics Committee) was not required.

Figure 1 Process for the cross-cultural adaptation and translation into French of the BSS-R.

Preparation

Four professional translators and the questionnaire’s original developer were contacted. Two native French speakers (T1, T2), fluent in English and experienced in PROM translation, completed the forward translation. Two English native speakers (T3, T4), fluent in French, performed the back translations.

Forward Translation

Two independent French versions (V1 and V2) were produced from the English source by T1 and T2.

Reconciliation

Together with the project manager (PM), T1 and T2 compared V1 and V2 to select the most suitable wording, ensuring semantic, idiomatic, experiential, and conceptual equivalence. This process generated a preliminary version (V3). The PM had prior expertise in PROMs for research and clinical purposes.

Back Translation

T3 and T4 independently translated V3 back into English, producing versions V4 and V5. Neither had access to the original questionnaire nor prior knowledge of the BSS-R or BSS.

Back Translation Review

The two back translations (V4, V5) were compared with the source version by the translators, the questionnaire developer, and the PM to identify mistranslations, omissions, or conceptual shifts. Discrepancies, if present, were resolved by revising V3.

Harmonization

The reconciled version was compared with existing translations in other languages by the PM to confirm consistency across versions.

Cognitive Debriefing

Fifteen participants tested V3 to assess clarity, interpretation, and cultural relevance. Comprehension was rated on a 10-point Likert scale (1 = not understood, 10 = fully understood). Scores ≤ 6 triggered participant feedback for alternative wording. An item was considered acceptable if its mean comprehension score was ≥ 7. Descriptive statistics were performed and quantitative data were summarized using the mean ± standard deviation (range).

Review of Cognitive Debriefing Results and Finalization

Feedback was jointly reviewed by clinicians, a PROM expert, translators, and the PM. Necessary adjustments were implemented to produce the final French version (VF).

Proofreading

The PM revised the VF for grammar and spelling.

Final Report

A detailed report summarized the adaptation process, justifying conceptual and linguistic choices and providing guidance for future translations.

Results

Forward Translation

Both forward translations were similar, however, one version (V1) was deemed better for its semantic equivalence, and therefore contributed significantly to the reconciled version (V3). Indeed, the first item (“I came through childbirth virtually unscathed”) was translated in V2 as “I gave birth almost without difficulty”. This translation was judged inappropriate by the research team (French clinicians, translators and researchers) as terms were too ambiguous. Furthermore, it did not convey the original meaning. The BSS-R did not contain colloquialism or idiomatic expressions, nor did it include items aimed at capturing culture-specific aspects of daily life experiences in the English context. Therefore, there was no issue in ensuring idiomatic and experiential equivalence. Similarly, there was no conceptual differences between the English and French cultures in this questionnaire.

Backward Translation

Both backwards translations showed high semantic equivalence, with no issue for idiomatic or experiential equivalence. Those two backward translations were checked by the original developer, who found both versions to be accurate translations. There was still no issue regarding idiomatic and experiential equivalence. A conceptual issue emerged for items 7 and 9 as the original questionnaire uses the word “distressing” while the English translation of the French word was “challenging”. However, the French word does convey an upsetting and stressful meaning, as intended to in the original questionnaire. Therefore, the V3 was not modified.

Cognitive Debriefing and Final Version

Sixteen French-speaking mothers who recently gave birth took part in the cognitive debriefing. One mother withdrew her consent a posteriori and was not included in the analyses. The mothers had a mean (± standard deviation) age of 36 ± 5 (range: 31–47). Among them, six (40%) had delivered by cesarean section and nine (60%) had a vaginal delivery. The overall level of comprehension was 9.5 ± 1.1. A detailed level of comprehension for each item is displayed in Table 1. Five ratings out of 150 (3%) were < 7 and concerned items 1, 3, 8 and 9. Two identical comments were made on item 10 despite ratings being > 7. During the cognitive review, comments on items 1 and 10 were deemed as improving the translation and were therefore retained in the final version Fr-BSS-R (Supplementary Material 1).

Table 1 Level of Comprehension of the 10 Items

Discussion

Childbirth is an essential milestone in life and how mothers experience this event is of great importance as it can have lasting benefits like self-empowerment and improving the bond with her child,^9,10 or in opposite ways, be a grueling moment generating post-partum depression or stress disorder.^3,4 The BSS-R is therefore increasingly used worldwide given it reliably measures women’s experience during labor. This study successfully developed the translation and cultural adaptation into French of the BSS-R (Fr-BSS-R), according to ISPOR recommendations, thereby enabling its use in the French-speaking population.

To adapt this questionnaire, the authors rigorously followed international standards including forward and backward translations, as well as a cognitive debriefing. Such a methodology is fundamental to achieve a culturally equivalent instrument.^34,38 During the forward and backward translations, the research team ensured that the semantic, idiomatic, experiential, and cultural equivalences were achieved. Both backward translations conveyed the same meaning to the original version and were deemed accurate by the original developer, validating the semantic equivalence.³⁹ Similarly, the research team was mindful of idioms, colloquialisms and situations that may not fit the French cultural context, but none of these were found, thus facilitating idiomatic, experiential, and cultural equivalences. As a result, the Fr-BSS-R was highly understood during the cognitive debriefing with the 10 items receiving a mean comprehension score superior to 8. Comments were made on verb tenses, or on wording, specifically to use the word “exhausting” rather than “distressing”. Those comments did not lead to any changes in Fr-BSS-R as it was not improving the adaptation. However, a comment on item 1 suggested that a specification of the domain (ie physical or mental) was needed to clarify the item, prompting the research team to add this precision for semantic equivalence purposes. This clarification was deemed important and was confirmed in the harmonization process. Indeed, this specification was also included in the Italian version, a western European country with a similar culture.²⁵ Similarly, comments on item 10 led to a modification to improve the cultural equivalence, as the literal translation from “hygienic” is more often used as an expression in French. Those modifications were made with the agreement of the original developer, professional translators, clinicians and researchers to make the best decision and create the more accurate adaptation.

This study has several limits as the research team (including translators, clinicians, and researchers) and the women participating in the cognitive debriefing were based in France or Switzerland. Consequently, the adaptation generated may not account for cultural differences in other French-speaking countries such as Belgium or Canada. Furthermore, although the adaptation process followed a thorough methodology - including forward and backward translations, a cognitive debriefing and involvement of the original developer - this study did not assess the psychometric properties of the Fr-BSS-R. Importantly, many international adaptations of the BSS-R that have followed the same methodological framework have subsequently demonstrated strong psychometric properties in a variety of cultural contexts. Nevertheless, the psychometric properties of the Fr-BSS-R should be evaluated in future research to confirm its suitability for use with larger and more diverse French-speaking populations.

Conclusion

A French-version of the BSS-R was successfully developed according to international recommendations for translation and cultural adaptation, involving both an expert committee and the target population. It can therefore be used among French-speaking mothers to assess childbirth satisfaction.